Healthcare Provider Details

I. General information

NPI: 1194231191
Provider Name (Legal Business Name): FAITHFUL ADULT DAYCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SAINT MATTHEWS RD
ST MATTHEWS SC
29135-8400
US

IV. Provider business mailing address

21 SAINT MATTHEWS RD
ST MATTHEWS SC
29135-8400
US

V. Phone/Fax

Practice location:
  • Phone: 803-655-5002
  • Fax: 803-655-5001
Mailing address:
  • Phone: 803-655-5002
  • Fax: 803-655-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberADC-0420
License Number StateSC

VIII. Authorized Official

Name: BETTYE RAVENELL
Title or Position: PRINCIPAL
Credential:
Phone: 803-655-5002